2841 DeBarr Road, Suite 40
Anchorage AK 99508
phone: 907-336-6375
fax: 907-336-7211
Rhene Merkouris, M.D. ~~ Billie-Jo Severin, PA-C ~~ Jillian Woodruff M.D.
1st OB Appointment Health History and Genetic History
Name:______DOB:___/___/____ Age:______
1st day of last period:___/____/____ Father of baby’s name______
Will you be 35 years old or over @ delivery? Yes No
General History
Please fill out this form completely to the best of your ability
ð Pregnancy history
o # pregnancies including now______
o # living children______
o # miscarriages______
o # abortions______
ð Religious or cultural consideration for your care?
o ______
ð Have you recently traveled outside of the country: Yes No
o If so, where?______
ð Do you have a pediatrician, if so who: ______
ð Hospital for delivery: Alaska Regional Providence
ð Occupation:______
ð Do you get your period every month: Yes No
ð How long does your period last?______days
ð How many days are between your periods: ______days
ð How old were you when you had your first period? ______
ð Were you using any birth control at conception: Yes No
ð When was your last pap? ___/____/______
o Any abnormal paps? Yes No
ð What was your pre-pregnancy weight?______pounds
ð Is blood transfusion acceptable in an emergency: Yes No
ð Do you have cats at home: Yes No
ð Have you had the chicken pox: Yes No
ð Do you have any allergies, if so what?______
ð Do you take any medications, vitamins or supplements? If so, what?
o ______
ð Have you ever used tobacco products? Yes No
o If yes, how many packs per day:______
o How many years have you smoked? ______
ð Do you currently use any tobacco products? (i.e cigarretes, ecigs) Yes No
o If no, when did you quit______
ð How many alcoholic drinks per week ______
ð Any alcohol, drugs or medication use since your last period? ______
ð How much caffeine per day do you consume?______
ð Do you currently or have a history of illicit drug use including MARIJUANA? If so, what?
o ______
Details of Past Pregnancies
Date / How many weeks at delivery? / Length of Labor / Weight of baby & Sex of baby / Epidural or spinal anesthesia? / Vaginal or c-section / Hospital and Doctor / Preterm labor / Procedures used in labor. i.e episiotomy, vaccuumFamily History for Self and Family
Please indicate if the relative is on your mother or father’s side of the family
ð Diabetes:
o Self:______
o Your family, if so who:______
ð High Blood Pressure:
o Self:______
o Your family, if so who:______
ð Autoimmune Disorders (i.e Rheumatoid Arthritis, Lupus, Type 1 Diabetes, Grave’s Disease): if so, what?
o Self:______
o Your family, if so who:______
ð Kidney Disease: if so, what?
o Self:______
o Your family, if so who:______
ð Frequent UTIs:
o Self:______
ð Neurological Disorders or Seizures: if so, what?
o Self:______
o Your family, if so who:______
ð Psychiatric Disorders (i.e Depression, Anxiety): if so, what?
o Self:______
o Your family, if so who:______
ð Hepatitis or Liver Disease: if so, what?
o Self:______
o Your family, if so who:______
ð Varicose Veins:
o Self:______
o Your family, if so who:______
ð Thyroid Dysfunction: if so, what?
o Self:______
o Your family, if so who:______
ð Trauma or Domestic Violence:
o Self:______
ð Blood Transfusion :
o Self:______
ð Pulmonary Disease (i.e asthma, TB) : if so, what?
o Self:______
o Your family, if so who:______
ð Breast Issues: if so, what?
o Self:______
o Your family, if so who:______
ð Any uterine abnormalities: ______
ð History of infertility:______
ð Any Surgeries or hospitalizations?
o Bad reactions to anesthesia
Date / Surgery / Reaction to anesthesia (Yes or No, if yes what happened)ð Any other history:
______
Genetic History for Self, Partner and Families
ð Are you from any of these heritages: None
o Italian Greek Mediterranean Asian
o Jewish Cajun French-Canadian African
ð Neural Tube Defects (i.e Spina Bifida, chiari malformation) None
o Your family:______
o Partner’s family:______
o Type: ______
ð Thalassemia (blood disorder) None
o Your family:______
o Partner’s family:______
o Type: ______
ð Congenital Heart Defect (i.e septum defects) None
o Your family:______
o Partner’s family:______
o Type: ______
ð Down Syndrome None
o Your family:______
o Partner’s family:______
ð Tay-Sachs Disease (blood disorder) None
o Your family:______
o Partner’s family:______
ð Sickle Cell Anemia or Sickle Cell Trait (blood disorder) None
o Your family:______
o Partner’s family:______
ð Hemophilia (blood disorder) None
o Your family:______
o Partner’s family:______
o Type: ______
ð Muscular Dystrophy None
o Your family:______
o Partner’s family:______
o Type: ______
ð Cystic Fibrosis or Carrier of Cystic Fibrosis None
o Your family:______
o Partner’s family:______
o Type: ______
ð Huntington Chorea None
o Your family:______
o Partner’s family:______
o Type: ______
ð Mental Retardation or Autism None
o Your family:______
o Partner’s family:______
o Type: ______
o Tested for Fragile X? ______
ð Maternal Metabolic Disorders- i.e Type One Diabetes, PKU None
o Your family:______
o Partner’s family:______
o Type: ______
ð Any children with birth defects None
o Your family:______
o Partner’s family:______
o Type: ______
Infection History
Infection TypeHepatitis B Immunization or acquired Hepatitis B / Self
Immunized: ______
Acquired:______
Exposure to TB (tuberculosis) / Self / Partner
Any history of genital herpes / Self / Partner
Rash or Viral Illness since last period / Yes
Which:______ / No
Any history of STIs, including HPV, Chlamydia, Gonorrhea, herpes / Self
Which type:______
Date:______ / Partner
Which type:______
Date:______
Any Other Comments or Concerns ______
Patient Authorization:
______
Signature Date
Witnessed by:
______
Signature Date
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